RENAL ARTERY STENOSIS

 

October 30, 2021

 34 YEAR OLD MALE MASON BY OCCUPATION CAME TO THE OPD WITH 

C/O Blurring of vision RE greater than LE since 3 yrs not associated with headache ,nausea , vomiting

Patient was apparently assymptomatic 3 yrs back ,while he was doing his work complained of giddiness and fell( black outs)non postural,not associated with nausea, vomitings,vertigo,tinnitus,earfull ness ,he was taken to a local hospital and was diagnosed with HIGH BLOOD PRESSURE ( used medication , unknown) for over 2 1/2 yrs 

C/O slurring of speech since 1 year ( progressive) 

C/O body pains since 1 year 

H/O giddiness 1 week back taken to local hospital ,was on medication ( unknown) 

No C/O chest pain , palpitations, shortness of breath ,pedal edema 

K/C/O HTN since 3 yrs (on past atenolol 50mg ,nicardia 10 mg,telma 40 mg)

Not a K/C/O DM,ASTHMA, EPILEPSY,TB

He is alcoholic (90ml /day)and smoker ( 2 per day)since 10 yrs 

No significant family history 

Vitals on admission:

BP: 270/140 mm hg 

 given Nicardia 20 MG and measured bp after 20 mins still the Bp was 270/140 mm hg 

PR : 90bpm

RR: 18 cpm

All the peripheral pulses present 

Ankle brachial index > 1.25 

Renal bruit present

BP:

         RT LT

UL 160/100 170/100

LL 200 200

Cvs : s1s2 + no murmurs

RS : Nvbs +

P/a : soft nontender

CNS : 

1) HMF - INTACT 

2)MOTOR SYSTEM : 

                      Right Left

Bulk: 

Inspection. N. N

Palpation. N. N

Tone: 

UL. N. N

LL. N. N

Upper Limb:

Shoulder: Flexion 5/5. 5/5

Extension. 5/5. 5/5 

Abduction: 5/5. 5/5 

Adduction: 5/5. 5/5 

Elbow: 

Flexion (biceps) 5/5. 5/5 

Extension (triceps) 5/5. 5/5

Lower Limb:

Ilio psoas. 5/5. 5/5

Gluteus max. 5/5 5/5

Adductor femoris. 5/5 5/5

Hamstrings. 5/5 5/5

Quadriceps. 5/5 5/5

Tibialis ant. 5/5 5/5

Tibialis post. 5/5. 5/5

Ex. Digitorum L. 5/5. 5/5 

Fl. Digitorum L. 4/5. 4/5

Ex. Hallucis L. 4/5. 4/5

Deep tendon reflexes:

Biceps: +2 +2

Triceps: +1 +1

Supinator: +2 +2

Knee: +3 +3

Ankle: +3 +3

Plantar: extensor flexor

Sensory:

STT: Crude touch. + +

Pain. + +

Temp. + +

Post. Dorsal

Fine touch. present

Vibration. + +

Position. + +

Cranial nerves : 

II - Blurring if vision present - Rt side > left side.

Visual acuity - Right side - only PL/PR present.

and hand movements perceived . Cant count fingers.

Left side - Counting fingers 3 m present.

III,IV,VI - Extra-ocular movements intact

ii) Pupil – Size - 4 mm - B/L NSRL

iii) Direct Light Reflex - Present.

V - i) Sensory -over face intact

ii) Motor – masseter, temporalis, pterygoids 

iii) Reflex

a. Corneal Reflex - present

b. Conjunctival Reflex - present

c. Jaw jerk - present.

VII - Slight deviation of mouth to left side .

IX ,X- Uvula deviated to right side .

Gag reflex intact.

XI, -normal

XII - no deviation of tongue .

CEREBELLUM : Heel knee test - normal

Finger nose couldn't be performed because of blurring of vision .

Horizontal Nystagmus present . Fast component to left side .

Couldn't perform Tandem gait .

Bp - Unequal in both arms .

All peripheral pulses felt and no asymmetry noted.

Cause for his renal artery stenosis?

could it be ? takayasu arteritis .

ACR criteria - for Takayasu arteritis .(in out pt)

1)Age of 40 years or younger at disease onset - present.

2)Claudication of the extremities - absent 

3)Decreased pulsation of one or both brachial arteries - absent ( equal on both sides )

4)Difference of at least 10 mm Hg in systolic blood pressure between arms - Present .

5) Bruit over one or both subclavian arteries or the abdominal aorta - absent over subclavian. heard over renal artery .

6)Arteriographic narrowing or occlusion of the entire aorta, its primary branches, or large arteries in the upper or lower extremities - 

We dont have evidence yet . have to get CT ANGIOGRAM done .

Diagnosis : HYPERTENSION SECONDARY TO RIGHT RENAL ARTERY STENOSIS WITH

GRADE IV HYPERTENSIVE RETINOPATHY WITH

RENAL ARTERY STENOSIS SECONDARY TO ? VASCULITIS ? TAKAYASU ARTERITIS WITH

LVH WITH RIGHT FACIAL PALSY WITH SLURRED SPEECH WITH DENGUE FEVER NS1 POSITIVE